Nuts and Bolts Management of Alcohol Problems in Primary Care

1. Nuts and Bolts Management of Alcohol Problems in Primary Care Dr Shahid Mohamed Dadabhoy, GP, Partner, Trainer and Tutor The Microfaculty, 107-109 Chingford Mount Road, Chingford, London E4 8LT shahid.dadabhoy@nhs.net

2. How do I make all of this Alcohol stuff work in the cold harsh unforgiving fluorescent light of a NHS Primary Care Monday morning?

3. A party political broadcast from the NHS Party

4. Who are these two men…?

5. Outline • Why manage alcohol problems in Primary Care at all? • How should we be managing Alcohol problems in Primary Care? • Identification and Brief Advice (IBA) • The Alcohol Use Disorders Identification Test (AUDIT) and why we should use it? • Putting it all together • RCGP Certificate In the Management of Alcohol Problems in Primary Care

6. Why manage alcohol problems in Primary Care at all?

7. The scale of the problem More than 20% of adults registered with a GP will drink in at least one of the following ways: Higher risk (Harmful) > 50 u/week; men > 35 u/week; women Increasing Risk (Hazardous) 22 – 49 u/week; men 15 – 35 u/week; women Binge > 8 units at once; men > 6 units at once; women

8. Why? (1) • Alcohol continues to have a harmful impact on many Individuals families and communities • 26% (around 10 million) of adults in England drink more than the lower-risk guidelines – 3–4 units of alcohol a day for men and 2–3 units of alcohol a day for women • Estimated cost of alcohol related harm to the NHS in England is £2.7 billion per year. (Statistics on alcohol; England 2009)

9. Why? (2) Between 15,000 and 22,000 premature deaths annually in England and Wales Nearly 5,000 (3.5%) cancer deaths per annum are attributable to alcohol 1,200 associated deaths per year due to haemorrhagic stroke 10% of deaths due to hypertension Liver Cirrhosis is now the 5th most common cause of death and continues to rise

10. Why? (3) Alcohol misuse in London • London has a higher proportion of dependent drinkers than any other region in England (Local Alcohol Profiles for England) • 11 to 15 year olds in London now drink the equivalent of 180,000 bottles of lager a week (London Assembly June 09) • Hospital rate for 11 to 15 year young women almost double for young men of same age (Profile of young Londoners’ drinking, 2009)

11. The Why (4)- It Costs…. • Alcohol related ambulance call out £ 188.00 • Alcohol related hospital admission £ 716.00 • Alcohol related A/E attendance £ 75.00 • Cost of Alcohol related Liver transplant £ 80,000 National Audit office 2008

12. Why? (5) Rate of alcohol-related admissions per 100,000 population (EASR)

13. Why? (6) PCT Comparison of rise in the Rate of admissions

14. Why? (7) Thinking laterally about Alcohol • Mental Health contacts e.g. QoF reviews for SMI, Depression etc • Overall lifestyle advice • Domestic violence • Other substance misuse • Injury • Contacts with Unscheduled Care • Contacts with Criminal Justice • Sexual Health contacts e.g. Emergency Contraception • Alcohol is both the most commonly used over he counter hypnotic and psychotropic agent.

15. Why? (8) Knowledge on Alcohol amongst Health Professionals can be poor? • Undergraduates and Postgraduates training grades are still taught the CAGE questionnaire. • Knowledge focussed on dependent drinkers • Little Practical Knowledge of how to address issues in Primary Care

16. The key to providing the most cost-effective care is to through a preventative and early intervention strategy to provide as little care as possible…

17. How should we be managing Alcohol problems in Primary Care?

18. How? • At every opportunity! • Proactively- go looking for problem drinking • In a wide range of presentations and contexts • By everybody in the practice. • Primary Care is well placed to do this

19. Alcohol Harm reduction StrategyImprove primary care responses Actions to support these objectives: • Provide Identification and Brief advise (IBA) to Higher risk and Increasing risk drinkers and refer those dependent on alcohol, into specialist treatment. • Develop guidance on management of alcohol in primary care.

20. The Dundee Story • Since the 1970s • Professor James David Edgar Knox, FRCP Edin Died: 10/08/2010 • The Dundee Courier • Dundee Sheriffs Court Proceedings on Thursdays

21. Identification and Brief Advice (IBA)

22. What is IBA? Identification and Brief Advice - Understanding units - Understanding risk levels - Knowing where the patient sits on the risk scale - Benefits of cutting down - Tips for cutting down

23. IBA Evidence base - For every eight people who receive simple alcohol advice, one will reduce their drinking to within lower-risk levels (Moyer et al., 2002) - This compares favourably with smoking cessation where only one in twenty will act on the advice given. (This improves to one in ten with nicotine replacement therapy.) (Silagy & Stead, 2003).

24. Benefits of IBA would result in the reduction from higher-risk to lower-risk drinking in 250,000 men and 67,500 women each year (Wallace et al, 1988). Risky drinkers are twice as likely to moderate their drinking 6 to 12 months when compared to drinkers receiving no intervention (Wilk et al, 1997). Can reduce weekly drinking between 13% and 34%, resulting in 2.9 to 8.7 fewer mean drinks per week, with a significant effect on recommended or safe alcohol use (Whitlock et al, 2004). Reductions in alcohol consumption are associated with a significant dose-dependent lowering of mean systolic and diastolic blood pressure (Miller et al, 2005).

25. What is a unit? How to calculate units? One unit is equivalent to 10ml or 8g of pure alcohol You can calculate the Units: - Volume (mls) X ABV( %) __________________ 1000 Tip: In a litre of any alcoholic drink its strength (%age) is also the total number of units, e.g. in one litre bottle of 40% strength vodka there are 40 units Drink Diary

26. What are the recommended lower-risk guidelines? 3–4 units of alcohol a day for men and 2–3 units of alcohol a day for women

27. The Alcohol Use Disorders Identification Test (AUDIT) and why we should use it?

28. Screening Tools in Primary care • Audit :Alcohol use and disorder identification (10 Questions) • Audit-C :Audit alcohol consumption questions (first 3 Questions of Audit) • Audit-PC :Audit primary care (5 questions of Audit) • FAST :Fast alcohol screening test (4 questions from Audit starting with a single screening question) • M-SASQ :Modified single alcohol screening question

29. AUDIT Questions • How often do you have a drink containing alcohol? • How many drinks containing alcohol do you have on a typical day when you are drinking? • How often do you have six or more drinks on one occasion? • How often during the last year have you found that you were not able to stop drinking daily once you had started? • How often during the last year have you failed to do what was normally expected of daily you because of drinking? • How often during the last year have you needed a first drink in the morning to get yourself daily going after a heavy drinking session? • How often during the last year have you had a feeling of guilt or remorse after drinking? • How often during the last year have you been unable to remember what happened the night daily before because of your drinking? • Have you or someone else been injured because of not in the during the your drinking? • Has a relative, friend, doctor, or other health care worker been not in the during the concerned about your drinking last year last year or suggested you cut down?

30. Why use the AUDIT family of assessment tools? • Cross-national standardization: the AUDIT was validated on primary healthcare patients in six countries It is the only screening test specifically designed for international use; • Identifies hazardous and harmful alcohol use, as well as possible dependence; • Brief, rapid, and flexible; • Designed for primary health care workers; • Consistent with ICD-10 definitions of alcohol dependence and harmful alcohol use • Focuses on recent alcohol use. • Integrated into GP software (if you actually look)

31. Audit-C and Audit c.90% accuracy for detecting heavy drinking (Bush et al) Currently regarded as the gold standard Audit C Scoring: A total of 5+ indicates increasing or higher risk drinking. An over all total score of 5 or above is Audit-C positive. Proceed to next 7 questions to complete full Audit

32. Full Audit Scoring • 0 – 7 Lower risk, • 8 – 15 Increasing risk, • 16 – 19 Higher risk, • 20+ Possible dependence • If Q. 4, 5 or 6 > zero = possible emergent or established dependence.

33. Putting it all together

34. Prochaska and DiClemente (1982) • Pre-contemplation (no consideration of changing) • Contemplation (thinking about changing) • Preparation (making plans to change) • Action (actually in the process of changing) • Maintenance (working to prevent relapse)

35. Measurement as an Intervention • Hawthorne Effect • Promoting Insight • “Booze gave me that John Wayne Feeling”

36. Delivering IBA First two tasks 1) Share the AUDIT score with the Patient, - How do you feel about this score ? Refer patient to the graph on the patient information leaflet measuring patient’s consumption against the general population. 2) Attempt to interest them in the idea that their drinking is possibly increasing risk or higher risk or dependent drinking It suggests you are drinking at a level that will be risky/ very risky for your health Would you be prepared to talk a little more about this? Refer patient to the “common physical and emotional effects” on the information sheet.

37. Delivering IBA next two tasks: 3) If they are interested, explore what benefits they might get from cutting down - Refer patient to this section of the information sheet Here is a list of benefits of cutting down – do any of them appeal to you? - Scaling Question for assessing readiness for change On a scale of 1-10, how important is it to you to be cutting down your drinking? 4) Discuss tips to cut down and ask the patient to keep a drink diary - Book a Follow-up appointment - Refer to alcohol services for extended advice as appropriate - Refer to specialist services if the score is 20+

38. Whilst waiting for a specialist assessment, advise the person to- reduce alcohol consumption somewhat where possible, but not to stop suddenly where there are concerns about precipitating problems from alcohol withdrawals Avoid activities where alcohol misuse may be hazardous (e.g. caring for children, swimming, driving). To consider involving friends and family in the treatment process, where possible. What advice should I give to a person who is dependent on alcohol?

39. Outcomes • Patients scoring: 0 – 7 Lower risk, give patient information leaflet. • For score of 8 – 15 (Increasing risk) and 16 – 19 (Higher risk):provide brief advice, give patient information leaflet and refer patients for extended advice if necessary to- e.g.Turning Point • For score of 20+ (Possible alcohol dependence) Community Drug and Alcohol Team (CDAT)

40. For more information: IBA: Alcohol Learning Centre website http://www.alcohollearningcentre.org.uk/eLearning/IBA/ http://www.alcohollearningcentre.org.uk/eLearning/Training/CommIBATrain/IBATrainRes/ AUDIT: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf

41. A couple of notes for commissioners…. “Always remember that your weapon was made by the lowest bidder” US Military “No bucks….No Buck Rodgers” NASA

42. RCGP Certificate In the Management of Alcohol Problems in Primary Care

43. RCGP Certificate in the Management of Alcohol Problems in Primary Care • Launched September 2009 • 1200 healthcare professionals have completed it • Epidemiology and Evidence Base of alcohol problems from a Primary Care perspective • Assessing Alcohol Intake • Screening for Alcohol Problems with the new tools AUDIT • Delivering IBA “at the coalface”-the bulk of the day involving key points in consulting styles. • Initial management of more dependent alcohol usage Medical Issues, Community Detox and Care Planning

44. The How ? (1) RCGP Certificate in the Management of Alcohol Problems in Primary Care The Department of Health Alcohol identification and Brief Advice e-learning course (done before the face to face training, 75%+ passmark) http://www.alcohollearningcentre.org.uk/eLearning/IBA/ One day training event. Self completed work book.

45. The How ? (2) Accessing the training day • National Events (…check the website) • Local Events (…pester your educationalists)

46. The How ? (3) Local training days You need: A RCGP Approved Trainer A minimum number of 5 people to attend any local event in order for it to be recognized by the RCGP. You also need (and the RCGP will not pay for): The Gig- the venue The Kit- the equipment (presentation AV) The Grub(s?!)- Catering

47. The How Much? …the sordid question of coin… • National Events- £250 • Local Events- £150 per course participant before the event – covers - registration for the certificate - educational pack materials It does not cover the cost of venue, approved trainers, equipment hire etc.

48. For more information • www.rcgp.org.uk/substancemisuse. • Ask me! Shahid Dadabhoy shahid.dadabhoy@nhs.net • Alcohol Certificate Coordinator RCGP Substance Misuse Unit Alcohol@rcgp.org.uk

49. Any questions?